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r.v. aox 14tua <br /> �* r <br /> Sonora CA 95370 <br /> f <br /> lite ch <br /> Ca: 623541 A-Haz <br /> Phone: 209-532-7320 <br /> Compliance without Compromise Fax: 209-533 . 2650 <br /> mai I(pal Itechpetro. co m <br /> Fill Spill Bucket Testing Report Form www•alitechpetro.com <br /> 1 . FACILITY INFORMATION <br /> Facility Name: Costo # 1091 Lodi Date of Testing : 05/17/17 <br /> Facility Address : 2680 Reynolds Ranch Rd . <br /> Facility Contact : Rick Medeiros Phone: 209 -366 -7332 <br /> Date Local Agency Was Notified of Testing : 04/24/17 <br /> Name of Local Agency Inspector (if present during testing): Cesar Ruvalcaba cruvalcaba@sicehd . com <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: Alltech Petro Inc, P . O . Box 4208, Sonora CA 95370 . (209) 532-7320 <br /> Technician Conducting Test : Isaac Anderson <br /> Credentials ® CSLB Contractor ® ICC Service Tech . ® SWRCB Tank Tester ❑ Other (Specify) <br /> License #(s) : CA-623541 A- HAZ ICC- 8146912- UT SWRCB 09 - 1749 <br /> 3 . SPILL BUCKET TESTING INFORMATION <br /> Test Method Used : ® Hydrostatic ❑ Vacuum LJ Other <br /> Test Equipment Used : One Hour observed test Equipment Resolution : 1 / 16" <br /> Identify Spill Bucket (By 1 87A Fill 2 87B Fill 3 91 Fill : 4 Additive Fill <br /> Tank Number, Stored <br /> Product, etc. <br /> Bucket Installation Type : ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury ❑ Direct Bury <br /> ® In Sump ® In Sump ® In Sump In Sum <br /> Wait time between <br /> applying vacuum/water 0 0 0 0 <br /> and start of test. <br /> Test Start Time (T,) : 9 : 00 am 9 :00 am 9 : 00 am 9 : 00 am <br /> Initial Reading (R,) : 5 3/4" above cap 51 /2 It above cap 5" above cap 51 /2 above cap <br /> Test End Time (TF) : 10 : 00 am 10 : 00 am 10 : 00 am 10 : 00 am <br /> Final Reading (RF) : 5 3/4" above cap 5 1 /2" above cap 5" above cap 5 1 /2" above cap <br /> Test Duration (TF — T,) : 1 . 0 hr 1 . 0 hr 1 . 0 hr 1 . 0 hr <br /> Change in Reading (RF - Rj) : 0 . 0 0 . 0 0 . 0 0 . 0 <br /> Pass/Fail Threshold or 1 / 16" 1 /16" 1 / 16" 1 / 16" <br />( Criteria : <br /> Test Result: ® Pass ❑ Fait Z Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Faii <br /> Comments — (include information on repairs made prior to testing, and recommended follow-up for failed <br /> tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> l hereby certify that all the information contained in this report is true, accurate, and in full compliance with <br /> legal requirements. <br /> Technician : " Date: 05/ 17/17 <br /> E <br />